162 



ABNORMAL CONDITION OF THE ANKLE-JOINT. 



nient of the fibula was directed from below 

 upwards, a little inwards, and very much for- 

 wards, so as to make with its shaft a remark- 

 able angle salient anteriorly; this bone had 

 been traversed by the fracture obliquely, from 

 above downwards and from before backwards. 

 The external malleolus was placed about 

 one inch and a quarter behind its usual situa- 

 tion, and was consequently dislocated at its 

 tibio-fibular articulation, having burst those 

 strong ligaments which connect these bones 

 together, and which are so seldom found to 

 yield. 



Luxation of the bones of the leg backwards 

 at the ankle-joint. A luxation of one or both 

 bones of the leg at the ankle-joint backwards, 

 whether the accident be what has been called 

 complete or incomplete, whether accompanied 

 with a fracture of the fibula, or merely with a 

 rupture of the ligaments, is a displacement 

 which must be considered exceedingly rare. 

 Boyer, in his valuable work, gives no case of 

 it from his own observation ; and in alluding 

 to such an accident, states that no author, to 

 his knowledge, has given a single example of 

 it. Sir A. Cooper evidently has not seen it; 

 for he says, " 1 have seen the tibia dislocated 

 in three different directions, inwards, forwards, 

 and outwards ; and a fourth species of disloca- 

 tion is said sometimes to occur, viz. back- 

 wards." Baron Dupuytren states that he has 

 never seen this accident.* 



Mr. Colles has given me the notes of one 

 case, and it is the only one he can, in his exten- 

 sive experience, recollect to have met with, of 

 a partial dislocation of the lower part of the 

 tibia and fibula backwards, and has also shewn 

 me the cast he had taken of the leg. In this 

 case the tibia seemed thrown partially back- 

 wards, from the articular pulley of the astraga- 

 lus; the fibula was unbroken, and was also 

 carried backwards with the tibia; the foot, 

 measured from the instep upon its dorsum, was 

 longer than that of the opposite side, the heel 

 was shorter and less pointed, the space in front 

 of the tendo Achillis, near to the os calcis, 

 was partially filled up, and a hard swelling oc- 

 cupied the lower and back part of the tibia, 

 which was evidently formed by a quantity of 

 callus, which had cemented together the frag- 

 ments of a fracture of the lowest part of the 

 tibia; the leg was shorter than the opposite 



1*1 ^ ^ 



limb. 



It would have been interesting to have learned 

 the precise manner in which this accident had 

 occurred; but as to this, or the immediate 

 symptoms which followed the injury, I could 

 get no satisfactory information. The man did 

 not apply to Stevens's Hospital until the bones 

 were united in their new and faulty position. 

 Besides the partial dislocation backwards of the 

 tibia, this bone with the outer malleolus of the 

 fibula was inclined somewhat outwards; and 

 the man walked lame and most awkwardly on 



* Je n'ai jamais vu de luxation du pied en avant, 

 dans les fractures du perone et de I'extremite du 

 tibia. Annuaire Medico-Chirurgical, 1819, Paris, 

 p. 159. 



the outer edge of the heel and foot, the inner 

 side of which was somewhat curved inwards. 



I have had occasion to notice a displace- 

 ment of the tibia backwards on the os calcis, 

 in a case where the astragalus sloughed in con- 

 sequence of a compound injury to the external 

 malleolus and ankle-joint; but such a case is 

 different from that now under our considera- 

 tion, although the possibility of such an occur- 

 rence should not be lost sight of. 



2. Morbid anatomy, a. Acute inflammation 

 of the synovial membrane of the ankle-joint 

 produces changes in the synovial fluid of the 

 articulation both in quantity and quality, and 

 alterations very generally in the appearance and 

 structure of the membrane ; I say very generally, 

 for I have known an exception to the rule, in a 

 case* of acute synovitis of the ankle-joint which 

 caused the death of the patient in fifty hours 

 from its first onset ; during the whole of the 

 time the patient never slept nor ceased to com- 

 plain of the agonizing pain of the ankle-joint. 

 At the post-mortem examination, before the 

 skin was removed, the extensors of the toes were 

 observed to be displaced by the fluid which 

 distended the synovial sac of the articulation, 

 and fluctuation was now, as during life, to be 

 felt in two tumours which existed in front of 

 the two malleoli ; the interior of the joint was 

 occupied by a turbid oily synovial fluid ; no 

 false membrane existed, and if there had been 

 increased vascularity during life, no trace of it 

 was discoverable at the time of examination : 

 increased quantity with altered quality of the 

 synovial fluid were the only deviations from 

 the normal condition which could be noticed. 

 Portions of the synovial membrane are, how- 

 ever, occasionally found covered with false 

 membrane. Pus has also been found in 

 the joint, sometimes laudable, sometimes 

 foetid, and of a brownish red colour; the 

 membrane has been found thickened, and has 

 afforded evidence of increased vascularity, and 

 even in some points has presented a villous ap- 

 pearance. In very young subjects I have known 

 acute inflammation of the ankle-joint in a few 

 days extend itself to the epiphysis, and produce 

 separation of it from the shaft of the tibia ; and in 

 such cases a displacement of the shaft inwards, 

 and of the epiphysis and foot outwards, occurs 

 from the action of the muscles, as in Pott's luxa- 

 tion. Acute inflammation commencing in the 

 synovial membrane of the ankle-joint sometimes 

 extends farther than this : there have been cases 

 in the Richmond Hospital, and the specimens 

 have been preserved in the museum, of acute 

 synovitis of the ankle in which the inflammation 

 extended through the vascular junction of the 

 epiphysis and shaft of the tibia, and having 

 occupied the cellular junction of the periosteum 

 with the anterior and inner surface of the tibia, 

 soon ended in the formation of pus and lymph, 

 which detached from the bone its immediate 

 covering, and produced effects which termi- 

 nated in the death of the patient. I have seen 

 this detachment of the lower epiphysis of the 

 tibia in an infant six days old, the result of acute 



* See Dublin Journal, vol. iv. p. 1. 



